Healthcare Provider Details

I. General information

NPI: 1033555982
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY OF OLDHAM COUNTYQ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2013
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BUCKNER CTR SUITE 3
LA GRANGE KY
40031-7790
US

IV. Provider business mailing address

1000 BUCKNER CTR SUITE 3
LA GRANGE KY
40031-7790
US

V. Phone/Fax

Practice location:
  • Phone: 502-222-8848
  • Fax: 502-222-9319
Mailing address:
  • Phone: 502-222-8848
  • Fax: 502-222-9319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7129
License Number StateKY

VIII. Authorized Official

Name: DR. TRACY LEANN KIM
Title or Position: DENTISTR/OWNER
Credential: DMD,MBA
Phone: 502-222-8848